Saturday, January 30, 2010

Before I get to the links two brief updates. Remember the teasers I was putting out regarding Health Canada? Well two things are slowing me down from giving you folks one doozy of a story. The first is that I'm waiting for an official response from Health Canada to a pile of questions I sent them. The second is that the Canadian Medical Association Journal has hired me to write the story for their news section and consequently rather than just have my snarky opinion and be done with it, I've got to do my due diligence and research all sides of the story, conduct piles of interviews and then write journalistically (see, here in the blog I can make up words) about it. I'm hoping for some time next month.

Second update? Tune into CBC Marketplace next Friday night and you can catch me on their piece on the pros and cons of Herbal Magic.

Friday, January 29, 2010

Will your writers actually figure out a way to explain things that isn't completely ridiculous or will you suffer the fate of Alias with writers that got a little too cute and smart for their ultimate good?

Who knows? One thing I do know however is that there are a lot of plots to juggle and lots of viewers to confuse - and that brings us to today's Funny Friday video (email subscribers, you've got to visit the blog).

Thursday, January 28, 2010

There have been a number of studies of late that have concluded that being overweight (not obese, overweight) and elderly is in fact a good combination.

Well, here's another.

This study, published today in the Journal of the American Geriatric Society has Leon Flicker and his colleagues discussing the impact of weight on mortality over a 10 year period in 9,240 Australian men and women.

Their findings?

The minimum mortality risk was found at a BMI of 26.6 and as BMI decreased from there, risk increased, with the risk of death with a BMI at the lower end of the "normal" range being nearly double the risk of those who were "overweight". These results were sustained even when stratified into groups of initially "healthy" versus initially "unhealthy" subjects and when years one, two and three were subtracted from the study to eliminate those who might have lost weight prior to enrolment due to a chronic illness.

The one variable aside from weight that had a tremendous impact was being sedentary. Men who were sedentary were found to have a 28% increased risk of mortality across all weight categories while for women the risk was double!

Class I Obese participants had very similar mortality risks to normal weight individuals though as weight went up from there, so too did risk.

The results aren't exactly surprising. Previous studies have shown the same results and certainly the theory that older folks carrying some excess weight will have greater metabolic reserves to draw on to weather both chronic and acute medical conditions sounds feasible.

The main limitation of this paper is that BMI was used as a surrogate measure of body fat. This becomes problematic in a geriatric population due to both the natural course of aging (loss of muscle and conversion to fat) as well as the fact that BMI does not identify those with greater stores of visceral fat. A minor limitation was that height and weight were self-reported and given that we know self-reported heights and weight tend to make people taller and skinnier than they actually are (a phenomenon that one might expect to be exacerbated by age-related shrinking (there's an easy paper for someone)).

Interestingly though the paper's main limitations actually supports the authors' conclusions that BMI thresholds as we currently understand them likely should not apply to the geriatric population in that either weight is in and of itself protective or that BMI cannot identify risk in the elderly though perhaps fat distribution does (another potential paper), and while the authors for some reason didn't mention it in their conclusion, this paper would certainly suggest that the most important thing a primary care physician might do when faced with an overweight or obese geriatric patient would be to constantly encourage them to be active.

Wednesday, January 27, 2010

You see that's the thing about evidence-based practice, you can't rule anything in or out until you've proven it does or doesn't work.

The latest proposed cure?

The Endobarrier (that's it up above).

Pretty simple concept. Endoscopically place the 2 foot long barrier in the proximal small intestine. In effect this mimics the "bypass" part of the gastric bypass where the proximal small intestine is bypassed by hooking up the new smaller stomach below it.

Mechanistically this ought to lead to malabsorption of calories though unlike the gastric bypass I wouldn't expect there to be any dietary restriction or a reduction in the hunger hormone ghrelin though with their add-on "Flow Restrictor" which delays stomach emptying, perhaps there'd be some of both of those effects as well.

According to GI Dynamics (the parent company), during a 12 week trial 10 morbidly obese patients with the Endobarrier and Flow Restrictor in place lost on average 36.7lbs with side effects including, "mild to moderate abdominal pain, nausea and vomiting."

With Endobarrier'ed type 2 diabetics (and no "Flow Restictor"), after a 28 week study their HbA1C levels (a measure of long term glycemic control) went down a remarkable 2.4 percentage points.

There's no long term data yet and while it's too soon for me to close up shop, given the ease of placement, the comparatively low cost ($2,000) and the effects to date, I'll be watching the Endobarrier with cautious curiosity.

Tuesday, January 26, 2010

You see most people have no idea what a Food Guide "serving" is and most of those who do probably don't pay them too much attention.

Health Canada actually did some research that suggested that the majority of Canadians didn't know what a "serving" was and that many simply thought it was whatever amount they put on their plates. While that research may no longer be found on their site (gone since roughly the time I started pointing it out) I did find this statement from a summary of regional meetings Health Canada held during the consultation phase of designing the new Food Guide,

"Confusion about serving sizes and serving ranges was identified most often as the concept that consumers have difficulty grasping."

And this one from the executive summary of the 2007 Food Guide coast-to-coast consultation,

"Survey results reveal that most respondents agree with the idea of removing the term “serving” from the Guide. Sixty-two per cent of respondents agreed that not using the term “serving” will help Canadians understand the difference between the amounts they eat and those shown in the Food Guide, and only 25 per cent disagreed (13 per cent were unsure)."

A shame that Health Canada didn't bother paying attention to their own research and surveys as it seems pretty clear - Canadians don't understand what "servings" are and the allied health professionals consulted coast-to-coast gave them a big thumbs down.

Well yesterday in the Hamilton Spectator Registered Dietitian Vicki Edwards explained the challenges of the Food Guide's rather arbitrarily sized "servings" by explaining to her readers why in fact it's easier to get those 7-10 servings of fruits and vegetables each day than they might think,

"often a single piece of produce is larger than one Food Guide serving, and just a few items can quickly add up over the day."

And that can be said to be true about all the categories in the Food Guide - really unless you're actually weighing and measuring everything, if you're aiming for the minimums, you're liable to be getting far too much.

Vicki rightly notes,

"If you are eating a large fruit such as a Mutsu apple, you may be having two to three servings in that one piece of fruit.

A medium potato can be compared in size to a small computer mouse. Some baking potatoes would count as two or more servings.

One Food Guide serving of salad or leafy greens is 250 mL or one cup. Visualize an open hand for each serving amount. A plateful could count as several servings

A Food Guide serving of juice or fresh apple cider is 125 mL or half a cup. That hot mug may give you two or more servings."

Easy-peasy, right?

What I'm getting at is that if someone were to pick up the Food Guide and try to get minimums, putting aside all of my other concerns regarding the obesigenicity of the Food Guide, if that person hits their minimums, without actually weighing and measuring every single thing that they eat, they're probably going to eat far too much.

Doesn't strike me as a particularly great plan in a country where obesity is a major public health concern. You think maybe it's even a stupid one?

Monday, January 25, 2010

Coincident with the publication of this blog post there's a press conference going on at the Courtyard Marriott in Toronto where the Heart and Stroke Foundation is presenting their 2010 Annual Report on Canadians' Health. This year the report's called,

"A Perfect Storm of Heart Disease Looming on Our Horizon"

The report cites some genuinely grave statistics,

"Between 1994 and 2005, rates of high blood pressure among Canadians skyrocketed by 77%, diabetes by 45% and obesity by 18% — affecting both younger and older Canadians. Moreover, even younger age groups are experiencing increases in risk: among those 35 to 49 years of age, for example, the prevalence of high blood pressure increased 127%, diabetes by 64% and obesity by 20% — all major risk factors for heart disease."

And Dr. Beth Abramson, a Heart and Stroke Foundation spokesdoctor, sums it up brilliantly,

"Canada is truly at a crossroads. As a society we need to decide if we are going to invest in making our society more heart healthy so we can reduce our future risk, or would we rather continue to pay for a healthcare system overwhelmed by cardiac patients."

Like all of the Heart and Stroke Foundation Annual Reports this report ends with multiple calls to action with Heart and Stroke Foundation issued directives for the Federal Government, Provincial Governments and for all Canadians.

Conspicuously absent? A call to action with directives for the Heart and Stroke Foundation.

I guess that's where I'll come in. Think of this as the missing last page of the report (and certainly if heads remain firmly implanted in the sand, a new annual feature at Weighty Matters):

To the Heart and Stroke Foundation:

1. Rebuild the Health Check Program.

- Actually have the Heart and Stroke Foundation's Health Check program adopt the Heart and Stroke Foundation's own recommendation for a daily maximal intake of 1,500mg of sodium and adjust the program's criteria to bring them in line with the Canadian Stroke Network and Blood Pressure Canada's recommendation that maximal per serving sodium be 200mg.

- Create more than just a yes or no seal of approval so that foods with check marks can actually be compared to one another as there are often far healthier choices to be made even within comparable Health Check'ed products themselves.

- Evaluate all of the foods in the marketplace so that foods healthier but not a party to health check can be identified by consumers.

- Eliminate beverages from the program. People should not be encouraged to drink their calories.

- Eliminate Health Check products where sugar is added as fruit juice concentrate or puree and in so doing recognize that sugar is sugar.

- Eliminate Health Check products containing processed and red meats and in so doing fall in line with organizations like the Canadian Cancer Society who unlike the Heart and Stroke Foundation, takes evidence-based nutrition seriously.

- Expand Health Check's nutrient criteria to include the literally dozens of nutritional determinants of health its current iteration ignores (right now the majority of Health Check categories only evaluate 3-4 nutritional criteria in awarding the seal).

- Eliminate restaurants from Health Check. The Heart and Stroke Foundation should be encouraging Canadians to eat out less and cook with whole foods more rather than enabling Canadians to eat out and feel a false security about their choices. "Less bad" is in fact still "bad".

2. Acknowledge the existence and importance of calories.

- Immediately add a robust energy expenditure online calculator and caloric education and guidance section to the Heart and Stroke Healthy Weight Action Plan which currently has only the most rudimentary caloric guidance.

- Issue a complementary report to go along with the "FAT - Saving a generation before it's too late" report on childhood obesity in Ontario that actually discusses the impact of calories consumed on the etiology of childhood obesity given that in the report as published, despite it being about childhood obesity, calories - the currency of weight - aren't mentioned even once.

- Add calories as a criteria to be considered for every product category in Health Check.

- Never again release any type of tool or report having to do with obesity without explicitly including and discussing calories.

3. Call for a revision to Canada's Food Guide

- The Heart and Stroke Foundation should call upon the federal government to immediately revise the Food Guide (reinforcing the Canadian Medical Association's call to have the Guide revised every 3-5 years to incorporate advances in our understanding of the impact of dietary choices on health) to provide useful guidance to Canadians on sodium consumption and thereby be consistent with our best evidence on sodium.

4. Buy a mirror

- Before criticizing federal and provincial governments, before chastising the public about their need to be more concerned about their determinants of health, the Heart and Stroke Foundation should take a good long look at themselves in the mirror. What might they see?

Health Check'ed vegetable juice with nearly a 3rd of their own daily recommended sodium maximum?

A front-of-package labeling program that thinks 3-4 nutritional determinants of food are all that matter?

Partnerships with Boston Pizza that lead to the sale of heart shaped pizzas on Valentines day (a practice akin to a lung association having a day where they promote cigarette sales in 7-11s where part of the proceeds of smoke sales would go to them)?

Reports on childhood obesity that don't mention the word calorie even once?

For such a proud and supposedly stalwart organization these glaring shortcomings besmirch their good name.

Perhaps Stephen Samis said it best in their own 2010 report,

"This is an embarrassment for all Canadians",

and while he wasn't referring to the mess I've highlighted above, he may as well have been.

Saturday, January 23, 2010

The BBC on how the FBI used a photograph of a Spanish politician to serve as the "cutting edge technology" that helped age an Osama Bin Laden photo (and likely make it unsafe for the Spanish politician to travel internationally).

Runners World on how you're almost certainly tying your shoes the wrong way.

The Chicago Tribune continues its excellent series on quackery and autism this time taking on the supplements.

Low Tech Magazine tells you everything you ever wanted to know about wood-powered automobiles (including the obvious fact that there are such things as wood-powered automobiles).

Forbes on how vaccine denialism has led to hundreds of unnecessary H1N1 deaths.

To see things graphically, click the graphic up top. Important to note too, the graphic up top doesn't reflect the fact that Exhibit A isn't actually a whole grain bread.

4 very different breads. 4 breads that are not nutritionally equivalent. Exhibit A's made with refined flour and has nearly double the sodium of whole grain Exhibit D. Exhibit C's got 37% more sodium than Exhbit D and is otherwise pretty much identical. Exhibit B's got 15% fewer calories, 12.5% less sodium and is made with healthier grain than Exhibit A. Yet they've all got the same singular Health Check. Put 'em all in a row and if you're using Health Check's to shop, they're all the same.

Front-of-package programs need to be far more robust than just a yay or nay.

(BTW - the Dempster's Healthy Way with ProCardio Recipe 100% Whole Grain Wheat Bread - looks like a pretty good bread. My house? We use the Dempster's 100% Whole Wheat Bread 'cause we like the lower calories and for us the trade off for sodium's alright as we're pretty good at keeping ours under check and fibre wise - we eat lots of fruits and veggies.)

Wednesday, January 20, 2010

"today industry is being given notice they have two years to reduce the levels of trans fats or Health Canada will regulate their use."

Well guess what? It's 214 days later than that 2 year free-pass deadline and nothing much has happened to suggest we're any closer to regulation.

Well perhaps that's not altogether fair. Something did happen recently. Suspiciously right before Christmas (suspicious in that the things governments release quietly while people are distracted right before Christmas are generally the things they want to sneak rather than trumpet into existence) Health Canada released their final set of trans-fat monitoring.

And as I've noted before, it's not as if Health Canada can't act quickly. Remember what it did with BPA in baby bottles?

"We have immediately taken action on bisphenol A, because we believe it is our responsibility to ensure families, Canadians and our environment are not exposed to a potentially harmful chemical."

And more recently with phthalates where Health Canada announced a ban on six phthalates compounds that the most recent comprehensive review article notes,

"Analysis of all of the available data leads to the conclusion that the risks are low, even lower than originally thought, and that there is no convincing evidence of adverse effects on humans. Since the scientific evidence strongly suggests that risks to humans are low, phthalate regulations that have been enacted are unlikely to lead to any marked improvement in public health."

So here we've got a known toxin with far more serious public health risks than BPA or phthalates, that's already enjoyed a failed 2 year free pass, and Health Canada still has done absolutely nothing.

Tuesday, January 19, 2010

And if you're not sure why, here's a reason - last week it concluded that butter's not inherently bad for you.

You see last week the American Journal of Clinical Nutrition released a meta-analysis that looked at all the prospective epidemiological studies looking at the relationship between dietary saturated fat intake and the risks of developing coronary heart disease, stroke and cardiovascular disease.

What did they find? 21 studies with followups of 5-23 years encompassing 347,747 subjects and virtually zero effect of saturated fat intake on heart disease, stroke or cardiovascular disease. To their incredible credit in their statistical analysis they specifically took into account the nature of the collection of the food records recognizing that food diarizing is fraught with error. The authors also posit that those studies that demonstrated benefit from reduction of saturated fat on heart disease may well have been a consequence not of the reduction of saturated fat but by the substitution of polyunsaturated fats in their place. They also propose that the type of carbohydrates used to replace saturated fat in those studies may have had a role in benefits.

So should you go and eat a stick of saturated fat, I mean butter? Probably not.

So is butter inherently unhealthy? Probably not.

That said, you're probably still far better off replacing butter with a margarine containing significant amounts of polyunsaturated fats.

Monday, January 18, 2010

Here's the story. There's this company out in Prince Edward Island (PEI) called UFIT. It was founded in 2002 and it aims to provide non-judgemental, safe places to promote exercise. As evidenced in the photograph above, UFIT classes generally take place in school gymnasiums and everyone is welcome - from children where kids under 10 are free with parents, through to seniors and the cost to attend is/was only $5/class or $45/ten classes with each class lasting an hour.

Sounds great right?

Well at least it did.

You see PEI's Eastern School District is effectively shutting them down. Apparently local gyms complained that the rates the schools were charging UFIT to rent their gymnasiums impacted on their businesses.

The Eastern School District's response? Despite the fact that there was no exclusivity to UFIT's booking of school gymnasiums, despite the fact that one might think the schools would want to encourage exercise, despite the fact that comparing group fitness classes held for an hour a day in a local school gymnasium to a full-on, all day gym is like comparing taking a night class in a community college with a carrying a full-course load in University, as of February 1st the school district's hiking up UFIT's rent, restricting UFIT to holding only 3 days of classes per week per gymnasium (down from 7), and banning UFIT classes during summer break, stat holidays, March break or storm days.

Want to see what the school board's apparently trying to shut down? Here's a report from the CBC on UFIT (email subscribers, you'll have to head to the blog to watch):

Does anyone have a clue what this school board's thinking? Are they upset that UFIT's actually found a way to use school gymnasiums to effectively help keep people fit?

Think this is horrible? It might not be too late to help. According to a discussion I read on UFIT's Facebook page the school trustee's final vote on this matter isn't until February 1st. Why not send an email to Dr. Sandy MacDonald and Robert Clow and tell them what you think - Dr. MacDonald's the Superintendent of Education for the District responsible and Robert Clow is the Chair of the Board of Trustees for this sad turn of events (UFIT and the rest of the Board of Trustees will be copied on the email as well - and of course feel free to post a copy of your email in the comments here)

[UPDATE: Please read the comments - perhaps this isn't as clear cut an issue as originally presented.]

[Hat tip and thanks to loyal blog reader, RD and former Islander Chelsey for tipping me off to the story and providing me with a pile of links to make this an easy post]

Thursday, January 14, 2010

Association does not imply causality yet my money says that this morning (I'm writing this yesterday afternoon) the media reports will be awash with the message that rising Canadian obesity rates may well be a consequence of declining Canadian levels of fitness (as evidenced from yesterday's publication of the Canadian Health Measures Survey).

Personally I would argue that if we're looking for causality it's far more likely that obesity has impacted on fitness rather than the other way around given that fitness doesn't burn nearly as many calories as would be fair.

As an example, here's a video from youtube (email subscribers need to head to the blog to view the video) pitting the treadmill vs. a pizza where the participants aim to illustrate why it is, "you can't out train a bad diet".

Ultimately I believe the evidence strongly suggests it has been the world's rising caloric intake that takes the lion's share of responsibility for fueling the global obesity epidemic, not declining fitness.

So looking at the flip side, could obesity impact on fitness levels? Of course. It's more difficult to exercise with more weight, some folks may be embarrassed to exercise due to their weight, while others may have developed co-morbidities that have impacted on their ability or desire to exercise. Less exercise due to excess weight would of course lead to declining levels of physical fitness.

Or maybe fitness and fatness aren't strongly related at all in either direction. The Canadian survey that's reporting declining fitness notes the decline has occurred since 1981. You know what else has happened since 1981? Cable TV, the Internet, XBOXes and instant messaging have all happened - 4 great reasons as to why fitness may be declining and if my assertion that fitness doesn't burn enough calories to dramatically impact on rising rates of obesity is correct then perhaps as far as a discussion surrounding obesity goes, declining physical fitness is more of a red herring having occurred as a consequence of non-obesity related modern age sloth.

Here's my concern. Fitness as a determinant of health is likely second in importance only to diet. My worry is that when personal or societal interventions to improve fitness as a means to combat obesity ultimately disappoint, that people will abandon fitness having forgotten or ignored the importance of fitness for fitness' own sake.

Wednesday, January 13, 2010

Last year the Institute of Medicine (IOM) revised their guidelines on weight gain in pregnancy.

The new recommendations state that obese women should gain between 11 and 20lbs during pregnancy (compared with a previous recommendation of 15lbs).

The Institute didn't stratify these recommendations to different classes of obesity and consequently whether you've got a BMI of 30 or a BMI of 45 the recommendations remain the same.

Many physicians (myself included) found this to be odd - both in terms of not stratifying recommendations for different obesity classifications and also for recommending any weight gain at all for women with moderate to severe obesity and this week a few like minded physicians took the IOM to task in an article published in the January issue of Obstetrics and Gynecology.

The issues of course are the risks for both mother and baby associated with maternal prenatal obesity. The authors suggest that weight gain during pregnancy and that gain's effect on subsequent weight gain in life (not losing post pregnancy),

"are causes of a permanent increase in weight for every BMI category and are significant contributors to the obesity epidemic and associated comorbidities"

They believe that the recommendations are skewed towards the theoretical health of the fetus only and fail to factor in weight gain's risks to the mother which include higher likelihoods of gestational diabetes, hypertension, operative deliveries, pre-eclampsia and neonatal complications which of course in turn put the fetus at risk.

The authors recommend that diet should be tailored for women of different classes of obesity resulting in gestational weight gains of 10lbs or less and in some, weight loss.

I couldn't agree more and while my sincere belief is that 1,500-2,000 calorie diets are sufficient to nourish a fetus and to effect in weight losses for pregnant women with class II and III obesity, thankfully there are studies underway to test that very hypothesis. Belief is a bad way to practice medicine.

Tuesday, January 12, 2010

A study published last week in the American Journal of Preventative Medicine estimated quality-adjusted life years lost to both smoking and obesity.

Rather than going into the nitty-gritty of the study, and rather than opining on whether or not their stats are true or just statistical sleight of hand, I think the evidence would suggest it quite fair to simply conclude that obesity, like smoking, is very bad for your health.

So how many Canadians die a year due to obesity and diet related diseases? Conservative estimates ring in at around 25,000.

What about H1N1? Well according to the Public Health Agency of Canada H1N1 has killed 415 Canadians.

So how much money do you think the government has spent on H1N1 flu preparedness, immunization and awareness? I've seen television commercials, radio commercials, and print ads and I can't even begin to imagine the cost of immunizing the public and organizing the flu clinics. I can't fathom the dollars involved.

Want to make the argument that we didn't know how bad H1N1 would be and that we had to spend the money and the resources just in case? Fine. Let's talk West Nile Virus.

West Nile virus is probably a better comparison because just like obesity there's no vaccine and just like obesity public health campaigns consequently have to focus on education and prevention. Every summer there are spraying campaigns, television and radio commercials and print ads paid for by the Government of Canada telling us about the importance of bug repellent, long sleeves and getting rid of standing water. I'd be surprised if the government weren't spending between $50-100 million annually on West Nile related activities.

So how many people does West Nile Virus kill? Well, since 2002 there have been 38 West Nile virus deaths in Canada with the last death occurring back in 2005.

So 25,000 obesity and diet related deaths a year and what type of interventions are we seeing? None - except of course the most recent Ontario effort that ultimately will make bariatric surgery more difficult to get.

When are we going to start seeing hundreds of millions of dollars being spent on revamping nutritional education in schools, reforming school/hospital and city food, launching public health educational campaigns on the importance of eating frequently and understanding the energy in part of energy balance, legislation to put calories on menus, tax breaks for fresh whole foods, the creation of an evidence based and energy aware Food Guide, etc.?

Can you imagine how much money and resources would be spent and how much public awareness would be stirred up if West Nile virus killed 25,000 people each and every year?

Isn't it time to start taking the number one preventable cause of death in Canada at least as seriously as a disease that in the past 8 years has only killed 38 Canadians and in the past 5 has killed none?

Lubetkin EI, & Jia H (2009). Health-related quality of life, quality-adjusted life years, and quality-adjusted life expectancy in new york city from 1995 to 2006. Journal of urban health : bulletin of the New York Academy of Medicine, 86 (4), 551-61 PMID: 19283489

Monday, January 11, 2010

Well KFC's been creating combination public works and public awareness campaigns. They pay cities nominal amounts of money and then they get to slap their ads on city property.

The latest (photograph above) city/towns to sell out were Indiana and Brazil, Kentucky who for the low, low price of $7,500 have allowed KFC to festoon their fire hydrants with advertisements for KFC's Fiery Grilled Wings.

This campaign builds on KFC's prior campaign where they filled potholes and then slapped the repairs with a KFC logo.

According to the Kentucky Department of Health 67% of Kentucky adults are obese or overweight (with obesity rates doubling since 1995) making Kentucky the 7th fattest State in the US.

Thursday, January 07, 2010

Regular readers of Weighty Matters may recall a blog post from December where I reviewed the new rules surrounding access to bariatric surgery in Ontario. To summarize my post I suggested that the new rules are meant to dramatically limit access to the surgery and that the limitation is a consequence of fiscal constraints and not like the Ministry has suggested, a move to increase access to care.

Well that post led to a news piece published a few days ago in the Canadian Medical Association Journal (to really understand the rest of this post you might want to take a moment to read the CMAJ story before continuing reading here, it's not long)

In the news piece there are some statements that were made by my colleague Dr. Dent that I want to discuss here.

Dr. Dent reports that the criteria will "streamline" the process and ensure that people, "who just barely met the criteria" won't get the surgery and ensure that, "people who really need it" will.

Streamline? Before this new system was established a family physician could apply to have their patients seen by a surgeon and have an approval and an appointment to meet the surgeon within 6-10 weeks. Now the wait in Ottawa is a minimum of 6 months to be seen in consultation just to determine if you'll even get a chance to be seen by a surgeon. It's important here to note that Ottawa only just opened its doors. Head over to Toronto where the doors have been open for a few years and even without these new hoops to jump through the wait there's roughly a year to have a consultation. Regarding those who "barely met the criteria" - aren't the criteria themselves meant to weed out people who don't need surgery? Furthermore, given the past few years worth of studies that have shown the incredible benefits of bariatric surgery isn't there a growing movement that suggests the current criteria are in fact far too strict?

Dr. Dent goes on to state that the determination of surgical need is a highly specialized area and that "the average family doctor is ill-equipped to make such a determination." He also suggests that patients need to be assessed to ensure they can tolerate the surgery because some are at too high a risk.

Determination of surgical need is far from highly specialized. There are certain criteria that need to be met and then some exclusionary criteria as well. Family physicians spent a minimum of 6 years in medical training and I'm quite confident if given a document spelling out who is, and who is not a surgical candidate, they'd be able to figure it out. What was lacking with the old system wasn't the skill of the physicians, it was education of the physicians and educating physicians would be as easy as spelling out the inclusionary and exclusionary criteria on the required application forms.

On the other hand, I would heartily agree with Dr. Dent that determining surgical risk is highly specialized. Of course traditionally that is something that's done by surgeons and anaethetists during or ancillary to a patient's surgical consultation.

So here's where I really have a tough time with Dr. Dent's comments. He notes regarding wait times for assessment,

"The precedent is there. We have these for joint replacements, we have the knee clinic at the Ottawa Hospital so if the physician is worried about somebody’s knees they send them here. They don’t do the assessment and the actual referral for surgery."

Bariatric surgery is not comparable to a joint replacement. Indeed people may suffer waiting for a year or two for joint replacement but that suffering doesn't tend to kill them or put them at risk for further permanent damage. Bariatric surgical patients on the other hand do die on waiting lists and given the incredibly high rate of medical comorbidity are at dramatically higher risk of developing or worsening complications of type 2 diabetes, hypertension, sleep apnea etc.

Next Dr. Dent states,

"If a patient has leukemia, they don’t do the treatment, they don’t refer for a specific treatment. They refer to a centre that deals with it."

That's true. And in fact I think cancer is a much more comparable condition to consider. Of course if my patient is found to have cancer and I want a consult with an oncologist to quarterback treatment it'll take me a few weeks, not a few years.

Oh, and about money. Dr. Dent mentions that it costs roughly $10,000 more per patient to send them to the US. That's true from an absolute dollar cost per procedure basis, but how much does it cost the health care system and the economy to have these patients wait for an additional year or two prior to their surgeries? There'll be the cost of two years of more frequent medical visits, certainly some hospitalizations, their medications, their days off work, increased rates of short and long term disability, decreased productivity etc. So to simply look at the cost of the surgery here versus the cost of the surgery there certainly isn't a fair comparison and doesn't take into account the realities of caring for these patients for the year or two they'll now be waiting.

Bob, if you could create a system that worked as efficiently as referrals to cancer centres, I'd be firmly behind you in promoting bariatric assessment centres. Of course they don't and won't work as efficiently as there are far more people with a need for bariatric surgery than there are folks newly diagnosed with cancer. The way I see it, what the new system will do best is dramatically delay people from receiving a life-saving, co-morbidity eliminating, quality of life improving surgery.

Now I know Dr. Dent and I know that he is an incredibly committed, sincere, and knowledgeable physician who has been a staunch advocate for obese patients for decades and really, I can't understand his positions at all. The Ministry's suggestion that the regional assessment centres will "streamline" access seems about as sensical to me as a mayor suggesting a rise in property taxes will save us all money.

Truly in my head this can only be about funding and Ontario not having enough of it to cover the surgeries. To me to say otherwise suggests either an incredible amount of cognitive dissonance or not being able to see the forest for the trees. More importantly to ignore the fiscal realities of the situation makes it far less likely that people will seek out innovative ways to figure out how to best fund this life-extending, life-improving procedure or to tweak a socialized medical system that's clearly coming apart at its seams.

Wednesday, January 06, 2010

You see the American Academy of Family Physicians published some interesting advertisements in their 2009 Healthy Living magazine, something they bill as part of their, "AAFP Patient Education Program".

So about which products did the AAFP want to educate patients?

The first was for a product called Ubiquinol which according to the published advertisement,

"Fights fatigue and rejuvenates an active lifestyle",

"Provides the spark for 95% of your body's energy production",

"Is essential in maintaining and protecting heart health",

and for aging Baby Boomers apparently its lack is,

"the key reason why your energy levels drop and you slow down"

Lofty claims, no? But wait, there's some teeny tiny fine print at the bottom of the ad that reads,

"These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent disease"

And we all know that everyone always reads the teeny-tiny fine print, right?

It gets worse. Much, much worse.

Next up is Chews-4-Health - a chewable dietary supplement designed by Dr. David Friedman, a chiropractor. Dr. Friedman has the very dubious distinction of being featured prominently on Quackwatch for his involvement with a product called Seasilver.

According to Quackwatch, Dr. Friedman was Chairman of Seasilver's advisory board and participated in infomercials that claimed Seasilver could cure cancer and other diseases. Thankfully the Federal Trade Commission reigned in Seasilver and banned Dr. Friedman from making unsubstantiated claims about it. Perhaps that's why Dr. Friedman has moved on to new ventures?

Oh and guess what? To make things even less savory Chews-4-Health appears to be a multi-level marketing scheme.

Chews4Health by the way, couldn't be more thrilled by the AAFP's seemingly tacit endorsement. Here's an excerpt from their November 2009 newsletter sent to their marketers (the emphasis by the way is theirs),

"Chews-4-Health has a powerful full-page ad in Healthy Lifestyle Magazine, which is sent to 95,000 family physicians each month! The American Academy of Family Physicians (AAFP) HAND PICKED Chews-4-Health for the coveted back inside cover, and offered EXCLUSIVITY—meaning Chews is the only dietary supplement advertising in the magazine!

Over 240 MILLION patients visit AAFP doctors each year!! Additionally, Chews-4-Health will be featured on its website, www.familydoctor.org, which gets 3.5 MILLION unique visitors each month!All sign-ups from these doctors go to the NLM"

Isn't it great that the American Academy of Family Physicians is including Chews-4-Health in their "AAFP Patient Education Program" and that they "hand-picked" it for the "coveted back inside cover"?

But don't worry, the AAFP don't actually stand behind their Patient Education Program so really, it's not their fault. You see despite hand-picking the ad and publishing Healthy Living magazine replete with the subheading, "Part of the AAFP Patient Education Program" the magazine has its own very small print disclaimer,

"Neither this book, nor its contents constitute an implied endorsement by the American Academy of Family Physicians (AAFP) or by Boston Hannah International of the products or services mentioned in advertising or editorial content."

And it's not just the ads they're not taking responsibility for,

"The editorial content in this publication does not necessarily represent policies or recommendations by AAFP."

Tuesday, January 05, 2010

You may remember my posts and podcast regarding the American Academy of Family Physicians (AAFP) and their unholy partnership with Coca Cola. According to the AAFP the partnership was established to provide much needed funds ($600,000) to revamp their website FamilyDoctor.org and to develop materials regarding how to healthily choose beverages.

Well I decided to tool around FamilyDoctor.org's new digs and see how they made out.

Want to know what I found?

Well they've made a lot of videos.

I decided to watch the ones that I thought ought to have mentioned the importance of minimizing sugary beverage calories. I watched:

The videos were beautifully produced yet wholly unhelpful. The information provided therein was just barely more useful than, "Buy Low and Sell High" to get rich in the stock market or, "Eat Less and Exercise More" to lose weight.

So were there specific directives to avoid sugar sweetened beverages?

Yes. One. In the Nutrition Fundamentals video there was a single one word mention of soft drinks in their inclusion in a list of foods with empty calories. Sadly reducing surgary beverages wasn't mentioned in any of the other videos.

Now to be fair, there are some mentions on FamilyDoctor.org's written materials that suggest sugar-sweetened beverages should be avoided - but of course those written materials were PCC (pre-Coca Cola).

Oh, and conspicuously absent from the site? Beverage and sweetener guidance information - the very same information the AAFP reported Coca Cola's monies were meant to fund.

[Think the Coke partnership's bad? Wait until you see tomorrow's post on who the AAFP is letting advertise in their "Patient Education Program".]

Monday, January 04, 2010

Clearly Health Canada's Natural Products Directorate is asleep at the wheel when it comes to weight loss drugs (and truth be told, all natural products).

In the past 2 years there have been 119 warnings issued by Health Canada regarding so-called "natural" weight loss remedies.

Not only is Health Canada ignoring the fact that to date there are no known significantly effective natural weight loss aids, they're clearly doing an awful job of ensuring that the products that they are allowing to steal Canadians' hard earned money and well-intentioned hope aren't in fact injected with prescription medications.

And for icing on the cake, this past December Health Canada announced that despite being now 6 years old, that it would be at least another year before the Natural Health Products Directorate actually did anything about ensuring natural health products met any criteria whatsoever.

Anyone out there want to take a bet that not only will it take longer than an additional year but that the criteria they establish will be woefully underpowered and still won't sweep the many miracles in a bottle that prey on defenseless Canadians off store shelves?

Want to know what I'm talking about?

Here are some scans from some local flyers:

(Oh, and by the way, this is not the Health Canada bombshell I was alluding to at the close of last year. Stay tuned for that one in the coming week or two)

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About Me

Family doc, Assistant Prof. at the University of Ottawa, Author of The Diet Fix, and founder of Ottawa's non-surgical Bariatric Medical Institute - a multi-disciplinary, ethical, evidence-based nutrition and weight management centre. Nowadays I'm more likely to stop drugs than start them. You can also follow me on Twitter and Facebook.

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